Sunday, October 16, 2011

A Physician's Credo

There was only one point to the Morbidity and Mortality conference. We ordered the xray. We could have looked at the result sooner. But how was I supposed to know? I was in my first week of internship and had no idea why my resident wanted an xray of a cellulitic leg.

The next day it became clear. The film showed pockets of gas. She had necrotizing fascitis. Within minutes the antibiotics were infusing. Within hours she was on her way to the OR. My fellow interns and I lined up at the back of the operating room. It was a particularly slow call day and there weren't any medicine patients to admit.

We watched as the surgeon expertly filleted opened her thigh. First pus and then black necrotic tissue. He took wide margins and then packed the wound. He didn't close up. He knew he would return to the OR multiple times in the next few days.

Miraculously she survived. Even with the delay, we evaluated and treated her infection far faster then the national average. A number of residents gathered at the door the day they wheeled her out of the hospital. Over her three month incarceration, many of us had taken care of her.

*

She bounced in and out of the hospital over the next year. After her original surgery, she developed bouts of intractable nausea and vomiting and would need to be admitted for intravenous fluids. She accepted each visit with serenity and calm. Her children and grandchildren surrounded her in the Emergency Room. It was as if she knew she was operating on borrowed time. Maybe the grim reaper had missed his chance once. But now he was circling in on his pray.

Between hospitalizations she came to see my partner in the residents clinic. She was physically fragile but mentally strong. She beamed as she talked about her family. Her blood sugars were atrocious. She spent most of her time in a wheel chair. But she was happy.

She returned to our clinic one last time. She had just been discharged from an outside hospital. Dangling from her neck was a central IV catheter that someone forgot to remove. The resident cut the sutures free with a scissor. He advised her to bear down as he pulled the length of the catheter out of her neck. She looked up and her eyes went blank. She took a deep breath and then fell over in her chair.

She was dead. Nothing about the next thirty minutes of resuscitation would change that. Father death had found a weakness in the fabric of her life and moved in swiftly. She may have escaped her fate once, but not twice.

*

As the years pass, I often think of her staring up at the resident as she was getting ready to have the catheter removed. An autopsy would later reveal no obvious cause of death.

As physicians, we have much less control of our patients destinies than we would like to admit. Sometimes, we are like a strong wind that blows the hand of fate inches in either direction.

Other times, we are like a gentle breeze bringing momentary relief to the fevered battle front, but rarely making an impact on the outcome.

So we try to be gentle and humble in our dealings with fate.

Often our true power comes not from altering that which we can't control but controlling that which we can.